1. The impact of triage on management of referrals to a pain service Cathy Price FPM Spring Meeting Newcastle 2010

2. Triage… A system used to allocate a scarce commodity, such as food, only to those capable of deriving the greatest benefit from it. French, from trier, to sort, from Old French

4. The Problem – Soton in 2002 50,000 care population-endless waiting list for specialist medical care pain cannot be managed Dodgy thinking had lead to dodgy expectations

5. Demand v capacity

6. Government Pilots - Shifting Care Closer to Home Our Health Our Car Our say: large patient survey – waiting times/ease of access most important 6 areas pilots started 2002 Orthopaedics ENT Surgery Gynaecology Urology Dermatology Review started 2006 & 18 week target introduced

7. Local Health Board’s expectations of Orthopaedic service? end the scatter gun effect for MSK referrals and doctor shopping Local access Informed choice Greater emphasis on pain managament

8. Overview 19 th March 2009

9. Keys to success High quality staff with clear roles and skills Effective team working As clear a picture as possible of the person being triaged Decision support tools to enable accurate signposting Validated questionnaires Easy access to investigations

10. Barriers to Change Professional : – knowledge low in primary care – Lack of confidence in non medical staff by doctors System: – Lack of joined upness – Unclear care pathways Data: – Routine hospital data lacked sufficient detail

11. Challenges “the rise and fall of the MPTT” British Orthopaedic Journal 2006

12. Professional - 1 Knowledge low in primary care – General Practitioners unable to select accurately patients for physiotherapy versus more skilled assessment lad to long queues Solution: – Administrators telephone questionnaire – 33% redirected within the service

13. Professional 2 - Improving clinical decision making - Decision Tools Pain Team unclear as to who to triage where Psychosocial factors scored – crude scale – Supported by: BDI/PainDetect/Bradford Needs Questionnaire MSK spinal assessment team: – Pain Catastrophising Scale – Pain self efficacy questionnaire – MRI using informed decision making tool – MBUR 6

14. Professional - – Physiotherapists not recognising psychosocial barriers Keele tools http://www.keele.ac.uk/research/pchs/pcmrc/dissemination/tools/startback University run courses on “yellow flags” Extended scope practitioner modular course High risk Medium risk Low risk Psychosocial obstacles to recovery – enhanced package – CBT practitioners Explanations – coaching/pain relief Reassurance, pain relief

15. System- Role of spinal surgery in care pathway Direct access to spinal surgery – confusing – Review of NICE guidance by Public health priorities committee – spinal surgery LOW PRIORITY. – Spinal surgeons agreed to end direct access for non emergencies 2010 – Map of Medicine pathway for spines

16. 16 Decision Aids reduce rates of discretionary surgery RR=0.76 (0.6, 0.9) O’Connor et al., Cochrane Library, 2009

17. 17 NHS Direct Forhealthadviceandreassurance,24hoursaday,365daysa year. 0845 4647 Search Home About this tool Resources References Glossary Sign out Home | 4. The treatment options | Lifestyle Changes 1. Introduction to knee arthritis 2. About you 3. How bad is your pain? 4. The treatment options Lifestyle Changes Weight Loss Exercise Physical Management Pain medications Injections Complementary Therapies Surgery 5. Comparing the treatments 6. Check your knowledge 7. What's best for you? 8. Your treatment choice 9. Your summary information 10. What's next? Lifestyle Changes Lifestyle changes Lifestyle changes have few risks, can reduce pain and improve mobility. Exercising and losing weight can benefit your overall health too. Self Management Everyone with a long-term condition such as knee arthritis tries to find their own way to help and cope with their problem; this is what we call self-management. However it is not always easy to find out about all the things that can help, and the best way of going about it. Taking control of managing your arthritis can have a life-changing impact on your wellbeing. It encourages an acceptance that arthritis affects you, but you do not allow it to control you. Education about arthritis and the support that is available are simple but powerful steps to regain control of your life, even if you have had arthritis for years. It can enable you to return to work and participate in everyday activities including social and recreational events. Ask your health professional about local "Self Care" courses or look at the websites listed in the resources section. Read more Weight Loss Exercise 4. The treatment options Physical Management OA Knee - Some Screen Shots

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20. Lack of” joined upness” Shared record systems – Paper notes – Hampshire Health care record – PACS - picture archive system

21. Data Large spreadsheets to measure processes Development of secondary user services data Kaiser system

22. Assurance Audit commission asked to review service- reported excellent outcomes Nominated site for Department of health review of “care closer to home” the estimated cost of the Orthopaedic Choice service was 39% less than the £2,840,916 which would have been incurred if all the referrals had been seen by secondary care providers.

23. Outcomes MSK triage - 2009/10 Mixture of Physiotherapists, Occupational therapists, podiatry, General practitioners – 3865 referred to MSK Triage – 1.2% referred to surgery

24. Outcomes Pain Triage Nurse.Physiotherapist.Occupational therapist + doctors at end – all referrals screened by medical staff according to locally agreed criteria 1500 referred - pop: 50,000 – c. 850 seen by MDT – 150 – re-referrals – problem solving session – 500 advice /further investigation not the right time Hospital care criteria : ED admissions, Strong opioids, dependency on medical model, under other services c 250 patients p.a.

25. 47% other pathway 34% Complex care management 19% community care Overall Outcomes of Assessment for Level of Need

26. User Surveys 88% felt the assessment process was about right 75% were satisfied with the outcome of assessment A small number were unclear as to the next step

27. City PCT Hampshire PCT National Musculoskeletal pain8980 70 Pain Intensity2527 23 Pain impact scale47 44 depression score (Beck)2925 ? Duration > 2 years8580 Case Mix

28. Other solutions? STEPS – Stephanie Davies Perth introduction of self care programme removed people from the waiting list in 45% Clark AJ, Beauprie I, Clark LB, Lynch M: A triage approach to managing a waiting list. Pain Research Management 2005; 10:3:155-7 – 600 triaged – 26% benefitted by written recommendations alone to primary care

29. Conclusions The magnitude of chronic pain can be managed by careful clinical and administrative processes Multiple barriers require careful solutions These systems are fragile and require excellent data and auditing.

30. References JOINT WORKING? An audit of the implementation of the Department of Health’s musculoskeletal services framework ARMA June 2009 Department of Health, A joint responsibility: doing it differently – the musculoskeletal services framework, 12 July 2006 NHS Institute Delivering Quality and Value Focus On: Musculoskeletal Interface Services NHS Institute for Improvement 2009 Shifting care from hospitals to the community: a review of the evidence on quality and efficiency. B. Sibbald, R. McDonald. M. Roland. J Health Serv Res Policy 2007;12:110-11